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Wa1h1n&on, D. C,, May 2, IQI.
The first edition of this booklet, a copy of which was sent to
every physician in the United States in January, 1911, has been of
great service in improving the quality of the returns of causes of
death, and has further aided in showing the importance of vital
statistics, of adequate legislation for this purpose, and of the thor
ough enforcement of existing laws. Besides its primary distribu
tion, many thousands of copies have been sent out by state and city
registration officials, and also by the bureau directly, to individual
physicians in connection with the work of obtaining more definite
statements of causes of death for the transcripts received from the
registration area.
In 1914 a second edition was issued in which the " List of Unde
sirable Terms" was somewhat amplified
This, the third edition, shows the rapidly growing extent of the
registration area for deaths, and calls attention to the increasing
interest in the subject, especially in the South, as well as to the
great need for more effective enforcement of laws for the registra
tion of births throughout the country.
The first and second editions were prepared under the direction
of Dr. Cressy L. Wilbur, former chief statistician for vital statistics,
and the present edition was prepared by Mr. Richard C. Lappin,
the present chief statistician for vital statistics of this bureau,
assisted by Mr. George H. Van Buren, expert chief of division.
Very truly yours,

Director of ike Census.

Secretary of Commerce.

[Second Decennial Revision, in effect January 1, 1910.]

NOTE.AU the states of the Union, also Alaska {Act of Con-

(. : gress April 25, 1913), now use or approve the United States Stand
ard Certificate of Death with the exception of Alabama, New
Hampshire, New Mexico, Rhode Island, and West Virginia. This
indicates great progress in the movement for uniform and com
parable statistics of causes ef death and occupational mortality
because in 1902, prior to the introduction of the Standard Cer
tificate, no two states and scarcely any two cities used precisely
the same forms of blanks for the registration of deaths. Following
is a reduced facsimile showing the portion for which information
is usually given by the physician or coroner (Medical Certificate
of Death) properly filled out:
Rev1sed United States Standard Certificate of Death.

In addition to the statement of cause of death, for which the

physician is responsible, it is desirable that he should also note the
correctness of the statements of Age, Special Occupation, and
Industry, as well as other important personal and statistical par
ticulars usually stated by the informant (see page a1).
In reporting causes of death the physician is requested to read
carefully the instructions upon the back of the certif,cate (see Stand
ard Certificate, copy of which will be sent on request).
The physician should enter
(1) THE DISEASE CAUSING DEATH (primary cause with
respect to time and causation), with its Duration from the begin
ning of the illness.
(2) Contributory Cause (or Causes) (secondary), with Dura
N. B.Duration, or approximate duration, should always be
stated. It should date from the beg1nning of the illness or the
origin of the condition, and not relate merely to the time under
observation or of confinement to bed. The primary cause is of
the longer duration. If the causes were entirely unrelated, one not
being a result or complication of the other, enter the disease most
important as the cause of death first, without regard to relative
duration, and strike out the word "Secondary" on the blank. In
naming the disease causing death it is urgently recommended
that the exact names printed in bold-faced type in the List below
be employed, whenever they are applicable, and that no other
terms be used instead. Thus, always write Typhoid fever; not
sometimes Typhoidfever, sometimes Enteric fever, or "Contin
uedfever" " Typhomalarial fever," etc. Of course many dis
eases are not given in the terms in bold-faced type below, but only
the most important ones. For others, any terms recommended by
the Nomenclature of Diseases of the Royal College of Physicians,
London (fourth edition, 1906), or the Nomenclature of Diseases
und Conditions of Bellevue and Allied Hospitals, New York (last
edition, 1911), may be used. Terms printed in italics are indeft
nite or otherwise undesirable, and should never be used when a
more definite statement can be given. " Heartfailure /' for ex
ample, is simply equivalent to cause of death unknown. "Con
vulsions," "Marasmus," " Debilitv" '' Old age" are terms of
this character. See List of Undesirable Terms (page 13), also
special instructions for deaths from Hxternal Causes (page n).
Please aid in the improvement of our vital statistics by using only
precise and definite terms.

1. Typhoid fever.
2. Typhus fever.
3. Eelapsing fever. [Insert "(spirillum)."]
4. Malaria.
5. Smallpox.
6. Measles.
7. Scarlet fever.
8. Whooping cough.
9- Diphtheria and croup-
ii. Miliary fever. [True Febris miliaria only.]
ii. Asiatic cholera.
13. Cholera nostras.
14. Dysentery. [Amebic? Bacillary ? Do not report ordinary
diarrhea and enteritis (104, 105) as dysentery.]
15. Plague.
16. Yellow fever.
18. Leprosy.
Erysipelas. [State also cause ; see Class XIII.]
19. Other epidemic diseases ;
Mumps ,
German measles,
Rocky Mountain spotted (tick) fever,
20. Purulent fever,and
infection etc.septicemia. [State also cause; see
Classes VII and XIII especially.]
21. Glanders.
22. Anthrax.
23. Rabies. [State also cause; see Class XIII.]
24. Tetanus.
25. Mycoses. [Specify, as Actinomycosis of lung, etc.]
26. Pellagra.
28. Beriberi.
Tuberculosis of the lungs.
29. Acute miliary tuberculosis.
30. Tuberculous meningitis.
31. Pott's
32. Abdominal tuberculosis.
disease. [Preferably Tuberculosis of spine.]
33. White swellings. [Preferably Tuberculosis 01 joint]
34. Tuberculosis of other organs. [Specify organ.]
35. Disseminated tuberculosis. [Specify organs affected.]
36. Rickets.
37. Syphilis.
38. Gonococcus infection.
39. Cancer1 of the buccal cavity. [State part.]
40. Cancer1 of the stomach, liver.
41. Cancer1 of the peritoneum, intestines, rectum.
42. Cancer1 of thefemale genital organs. [State organ.]
43. Cancer1 of the breast.
44. Cancer1
45. Cancer1 of of other
the shin. [State part.]
or unspecified organs. [State organ.]
46. Other tumors (tumors of thefemale genital organs excepted.)
[Name kind of tumor and
47. Acute articular rheumatism. [Always organ affected.
state Malignant?]
M rheumatism "
as acute or chronic]
48. Chronic rheumatism [preferably Arthritis deformans] and
50. Scurvy.
Diabetes. [Diabetes mellitus.]
5x. Exophthalmic goiter.
52. Addison's disease.
53. Leukemia.chlorosis. [State form or cause. Pernicious ?]
54. Anemia,
55. Other general diseases:)
Diabetes insipidus,
Purpura haemorrhaglca, etc.
56. Alcoholism (acute or chronic).
I " Cancer and other malignant tumors." Preferably reported as
Carcinoma of , Sarcoma of , Epithelioma of , etc
stating the exact nature of the neoplasm and the organ or part 01
the body first affected.
57. Chronic lead poisoning. [State cause. Occupational?]
58. Other chronic occupation poisonings. [State exact name o
poison, whether the poisoning was chronic and due to oc
cupation, and also please be particularly careful to see that
the Special Occupation and Industry are fully stated. I
the occupation stated on the certifcate is not that in which
the poisoning occurred- add the latter in connection with the
statement of cause of death, e. g., "Chronic occupational
phosphorus necrosis (dipper, match factory, white phos
phorus)." Give full details- including pathologic conditions
contributory to death. Following is a List of Industrial
Poisons (Bull. Bureau of Labor, May, 1912) to which the
attention of physicians practicing in industrial communities
should be especially directed:
Acetaldehyde, Formaldehyde,
Acridine, Hydrochloric acid.
Acrolein, Hydrofluoric acid,
Ammonia, Lead (57),
Ainyl acetate, Manganese dioxide.
Amyl alcohol, Mercury,
Aniline, Methyl alcohol,
Aniline dyestuffs [name] , Methyl bromide,
Antimony compounds Nltraniline,
[name] , Nitrobenzol,
Arsenic compounds [name], Nitroglycerin.
Arsenlureted hydrogen. Nitronaphthalene,
Benzine, Nitrous gases,
Benzol, Oxalic acid,
Carbon dioxide, Petroleum,
Carbon dlsulphlde, Phenol,
Carbon monoxide (coal va Phenylhydrazlne,
por, illuminating water Phosgene,
gas, producer gas), Phosphorus (yellow or
Chloride of lime, white),
Chlorine, Phosphorus sesquisulphide,
Chlorodinitrobenzol, Phospbureted hydrogen,
Chloronitrobenzol, Picric acid,
Chromium compounds Pyridine,
[name] , Sulphur chloride.
Cyanogen compounds Sulphur dioxide,
[name], Sulphureted hydrogen,
DIazomethane, Sulphuric acid,
Dimethyl sulphate, Tar,
Dinitrobenzol, Turpentine oil.
Not all substances in the preceding list are likely to be reported
as causes of death, but the physician should be familiar with it in
order to recognize, and to report, if required, cases of illness, and
should also be on the alert to discover new forms of industrial poi
soning not heretofore recognized. In the Bulletin cited full details
may be found as to the branches of industry in which the poisoning
occurs, mode of entrance into the body, and the symptoms of poi
soning. Attention should also be called to industrial infection,
e. g.. Anthrax (22), and the influence of gases and vapors, dust,
or unhygienic industrial environment].
59. Other chronic poisonings :
Chronic morphinism.
Chronic cocainlsm, eto.


60. Encephalitis. ' .
61. Meningitis:
Cerebrosplnal lever or Epidemic cerebrosplnal menin
Simple meningitis. [State cause.]
62. Locomotor ataxia.
63. Other diseases of the spinal cord :
Acute anterior poliomyelitis,
Paralysis agltans,
Chronic spinal muscular atrophy.
Primary lateral sclerosis ol spinal cord,
Syringomyella, etc.
64. Cerebral hemorrhage, apoplexy.
65. Softening ofthe brain. [State cause.]
66. Paralysis without specified cause. [State form or cause.]
67. General paralysis ol the insane.
63. Other forms of mental alienation. [Name disease causing
death. Form of insanity should be named as CONTEIBU
TOEY CAUSE only, unless it is actually the disease causing
69. Epilepsy.
70. Convulsions (nonfuerferal} . [State cause.]
71. Convulsions of infants. [State cause.]
72. Chorea.
73. Neuralgia and neuritis. [State cause.]
74. Other diseases of the nervous system. [Name the disease.]
75. Diseases o the eyes and their annexa. [Name the disease.]
76. Diseases of the ears. [Name the disease.]
77. Pericarditis. [Acute or chronic; rheumatic (47), etc.]
78. Acute endocarditis. [Cause? Always report "endocar
ditis" or "myocarditis" as acute or chronic. Do not
report when mere terminal condition.]
Acute myocarditis.
79. Organic diseases of the heart : [Name the disease.]
Chronic valvular disease, [Name the disease.]
Aortic insufficiency,
Chronic endocarditis, [See note on (78).]
Chronic myocarditis, [See note on (78).]
Fatty degeneration of heart, etc.
80. Angina pectoris.
81. Diseases of the arteries, atheroma, aneurism, etc.
82. Embolism and thrombosis. [Stateorgan. Puerperal (139)?]
83. Diseases of the veins (varices, hemorrhoids, phlebitis, etc.).
84. Diseases of the lymphatic system (lymphangitis, etc.).
[Cause? Puerperal?]
85. Hemorrhage : other d,seases of the circulatory system.
Cause? Pulmonary hemorrhage from Tuberculosis ol
lIngs (28)? Puerperal?]

. eses o e yro oy. ae ease.

89. Acute bronchitis. \ [Alwaysstateasacuteorchronic. Was
90. Chronic bronchitis, j* it tuberculous ? ]
91. Bronchopneumonla. [If secondary, %i\t primary cause ''
92. Pneumonia. [If lobar, report as Lobar pneumonia.]
93. Pleurisy, [Cause? If tuberculous, so report (28).]
94. Pulmonary congestion, pulmonary apoplexy. [Cause ?]
95. Gangrene of the lung.
96. Asthma. [Tuberculosis?]
97. Pulmonary emphysema.
98. Other diseases of the respiratory system (tuberculosis ex
u Pulmonary [Suchhemorrhage"
indefinite returns as "Lunghere,
etc., compiled trouble"
statistics. Tuberculosis of lungs (28) ? Name the disease.]
(V.Diseases of the Digestive System.)
99. Diseases of the mouth and annexa. [Name disease.]
100. Diseases of the pharynx. [Name disease. Diphtheritic ?]
Streptococcus sore throat.
io1. Diseases of the esophagus. [Name disease.]
102. Ulcer of the stomach.
103. Other diseases of the stomach (cancer excepted). [Name
disease. Avoid such indefinite terms as "Stomach trouble"
"Dyspepsia" "Indigestion" "Gastritis" etc., when used
104. Diarrhea and enteritis funder 2 years).
105. Diarrhea and enteritis (2 years and over).
106. Ankylostomiasis. [Better, for the United States, Hookworm
disease or Uncinariasis.]
107. Intestinal parasites. [Name species.]
108. Appendicitis and typhlitis.
109. Hernia, intestinal obstruction. [State form and whether Stran
Strangulated Inguinal hernia (operation).
Volvulus, etc. "
no. Other diseases of the intestines. [Name disease.]
in. Acute yellow atrophy of the liver.
112. Hydatid tumor of the liver.
113. Cirrhosis of the liver.
114. Biliary calculi.
115. Otherdiseases of the liver. ["Liver complaint" is not a sat
isfactory return.]
116. Diseases of the spleen. [Name disease.]
117. Simple peritonitis (nonpuerperal). [Give cause.]
118. Other diseases of the digestive system (cancer and tubercu
losis excepted). [Name disease.]
and Annexa.)
119. Acute nephritis. [State primary cause, especially Scarlet
fever, etc. Always state "nephritis" as acute or chronic]
120. Bright's disease. [Better, Chronic interstitial nephritis,
Chronic parenchymatous nephritis, etc. Never report
mere names of symptoms, as" Uremia" " Uremic coma"
etc. See also note on (119).]
121. Chylurla.
122. Other diseases of the kidneys and annexa. [Name disease.]
123. Calculi of the urinary passages. [Name bladder, kidney.]
124. Diseases of the bladder. [Name disease.]
Cystitis. [Cause?]
125. Diseases of the urethra, urinary abscess, etc. [Name dis
ease. Gonorrheal (38)?]
126. Diseases of the prostate. [Name disease.]
127. Nonvenereal diseases of the male genital organs. [Name
128. Uterine hemorrhage (nonpuerperal). [Cause?]
129. Uterine tumor (noncancerous). [State kind.]
130. Other diseases of the uterus. [Name disease?}
Endometritis. [Cause? Puerperal (137)?]
131. Cysts and other tumors of the ovary. [State kind.]
132. Salpingitis and other diseases of the female genital organs.
[Name disease. Gonorrheal (38)? Puerperal (137)?]
133. Nonpuerperal diseases of the breast (cancer excepted).
[Name disease.]
(VII.The Pueepeeal State.)
Note.The term puerperal is intended to include pregnancy,
parturition, and lactation. Whenever parturition or miscarriage
has occurred within one month before the death of the patient, the
fact should be certified, even though childbirth may not have
contributed to the fatal issue. Whenever a woman of childbearing
age, especially if married, is reported to have died from a disease
which might have been puerperal, the local registrar should require
an explicit statement from the reporting physician as to whether
the disease was or was not puerperal in character. The following
diseases and symptoms are of this class :
Abscess ofthe breast, Metroperitonitis,
Albuminuria, Metrorrhagia,
Cellulitis, Nephritis,
Coma, Pelviperitonitis,
Convulsions, Peritonitis,
Eclampsia, Phlegmasia alba dolens,
Embolism, Phlebitis,
Endometritis, Pyemia,
Gastritis, Septicemia,
Hemorrhage {uterine or Sudden death,
unqualified ) , Tetanus,
Lymphangitis, Thrombosis,
Metritis, Uremia.
Physicians are requested always to write Puerperal before the
above terms and others that might be puerperal in charactsr, or to
add in parentheses (Not puerperal), so that there may be no possi
bility of error in the compilation of the mortality statistics; also
to respond to the requests of the local registrars for additional infor
mation when, inadvertently, the desired data are omitted. The
value of such statistics can be greatly improved by cordial cooper
ation between the medical profession and the registration officials.
If a physician will not write the true statement of puerperal charac
ter on the certificate, he may privately communicate that fact to
the local or state registrar, or write the number of the International
list under which the death should be compiled, e. g., " Peritonitis
134. Accidents! of pregnancy : [Name the condition.]
Abortion, [Term not used in invidious sense ;
abortion should be so specified (184).]
Ectopic gestation,
Tubal pregnancy, etc.
135. Puerperal hemorrhage.
1 In the sense of conditions or operations dependent upon preg
nancy or labor, not " accidents " from external causes.
136. Other accidents1 of labor : [Name the condition.]
Caesarean section,
Forceps application.
Breech presentation.
Difficult labor.
Rupture oiuterus In labor, etc.
137. Puerperal septicemia.
138. Puerperal albuminuria and convulsions.
139. Puerperal phlegmasia alba dolens, embolus, sudden death.
140. Following childbirth (not otherwise defined), fDefine.]
141. Puerperal diseases of the breast. [Name disease.]
(VIII.Diseases of the Skin and Cellulae Tissue.)
142. Gangrene. [State part affected, Diabetic (50), etc.]
144. Furuncle.
Acute abscess. [Name part affected nature, or cause.]
145. Other diseases of the skin and annexa. [Name disease.]
(IX.Diseases of the Bones and of the Oegans of
146. Diseases of the bones (tuberculosis excepted): [Name dis
Osteoperiostitis, [Give cause.]
Necrosis, [Give cause.]
Mastoiditis, etc. [Following Otitis media (76) ? ]
147. Diseases of the joints (tuberculosis and rheumatism excepted).
[ Name disease ; always specify Acute articular rheumatism
(47), Arthritis deformans (48), Tuberculosis ot joint
(33/, etc-, when cause is known.]
148. Amputations. [Name disease or injury requiring amputa
tion, thus permitting proper assignment elsewhere.]
149. Other diseases of the organs of locomotion. [Name disease.]
150. Congenital malformations (stillbirths not included): [Do
not include Acquired hydrocephalus (74) or Tuberculous
hydrocephalus (Tuberculous meningitis) (30) under this
Congenital hydrocephalus,
Congenital malformation of heart,
Spina bifida, etc.
(XI.Diseases of Eaely Infancy.)
151. Congenital debility, icterus, and sclerema: [Give cause
Of debility.]
Premature birth,
Atrophy, [Give cause.]
Marasmus, [Give cause.]
Inanition, etc. [Give cause.]
152. Other diseases peculiar to early infancy:
Umbilica I hemorrhage,
Injury by forceps at birth, etc.
153. Lack of care.
1 In the sense of conditions or operations dependent upon preg
nancy or labor, not " accidents" from external causes.
(XII.Old Age.)
154. Senility. [Name the disease causing the death f the old
(XIII.Affections Peoduced by Exteenal Causes.)
Note.Coroners, medical examiners, and physicians who certify
to deaths from violent causes, should always clearly indicate the
fundamental distinction of whether a death was due to Accident,
Of death. orThe
Homicide; and "probably'1
qualification then state themay
Means or instrument
be added when nec
155. Suicide by poison. [Name poison.]
156. Suicide by asphyxia. [Name means of death.]
157. Suicide by hanging or strangulation. [Name means of
158. Suicide by drowning.
159. Suicide by firearms.
160 Suicide by cutting or piercing instruments. [Name instru
i6z. Suicide by jumping from high places. [Name place.]
162. Suicide by crushing. [Name means.]
163. Other suicides. [Name means.]
164. Poisoning by food. [Name kind of food.]
165. Other acute poisonings. [Name poison; specify Accidental.]
166. Conflagration. [State fully, as Jumped from window of
burning dwelling, Smotheredburning of theater, Forest
fire, etc.]
167. Burns (conflagration excepted). [Includes Scalding.]
168. Absorption of deleterious gases (conflagration excepted):
Asphyxia by illuminating gas (accidental),
Inhalation of (accidental), [Name gas.]
Asphyxia (accidental), [Name gas.]
Suffocation (accidental), etc. [Name gas.]
169. Accidental drowning.
170. Traumatism by firearms. [Specify Accidental.]
171. Traumatism by cutting or piercing instruments. [Name
instrument. Specify Accidental.]
172. Traumatism by fall. [For example, Accidental fall from
173. Traumatism in mines and quarries:
Fall of rock in coal mine,
Injury by blasting, slate quarry, etc.
174. Traumatism by machines. [Specify kind of machine, and if
the Occupation is not fully given under that head, add suffi
cient to show the exact industrial character of the fatal
injury. Thus, Crushed by passenger elevator; Struck by
piece of emery wheel (knife grinder); Elevator accident
(pile driver), etc.]
175. Traumatism by other crushing :
Railway collision,
Struck by street car.
Automobile accident,
Run over by dray,
Crushed by earth in sewer excavation, etc
176. Injuries by animals. [Name animal.]
177. Starvation. [Not "inanition" from disease.]
178. Excessive cold. [Freezing.]
179. Excessive heat. [Sunstroke.]
i3o. Lightning.

181. Electricity (lightning excepted). [How? Occupational?]

182. Homicide by firearms.
183. Homicide by cutting or pfercing Instruments. [Nam in
184. Homicide by other means. [Name means.]
185. Fractures (cause not s^cci/Led). [State means of injury. The
nature of the lesion is necessary for hospital statistics but
not for general mortality statistics.]
186. Other external causes:
Legal hanging,
Legal electrocution,
Accident, injury, or traumatism (unqualified). [State
Means of inlury.]
NOTE.If physicians will familiarize themselves with the nature
and purposes of the International List, and will cooperate with
the registration authorities in giving additional information so that
returns can he properly classified, the number of deaths compiled
under this group will rapidly dimmish, and the statistics will he
more creditable to the off,ce that compiles them and more useful
to the medical profession and for sanitary purposes.
187. Ill-defined organic disease :
Dropsy, Ascites, etc. [Name the disease of the heart,
liver, or kidneys in wh1ch the dropsy occurred.]
188. Sudden death. [Give cause. Puerperal ? ]
189. Cause of death not specified or ill-defined. [It may be ex
tremely difficult or impossible to determine definitely the
cause of death in some cases, even if a post-mortem be
granted. If the physician is absolutely unable to satisfy
himself in this respect, it is better for him to write Unknown
than merely to guess at the cause. It will be helpful if he
can specify a little further, as Unknown disease (which
excludes external causes), or Unknown chronic disease
(which excludes the acute infective diseases), etc. Even
the ill-defined causes included under this head are at least
useful to a limited degree, and are preferable to no attempt
at statement. Some of the old " chronics," which well-
informed physicians are coming less and less to use, are
the following : Asphvxia ; Asthenia ; Bilious fever ;
Cachexia ; Catarrhal fever ; Collapse ; Coma ; Conges
tion; Cyanosis; Debilitv; Delirium; Dentition; Dysp
nea; Exhaustion; Fever; Gastric fever ; HEART
FAILURE; Labarotomy ; Marasmus; Paralvsis of the
heart; Surgical shock ; and Teething. In many cases so
reported the physician could state the disease (not mere
symptom or condition) causing death.]

As a result of the conferences between the Committee on Nomen-

1ture and Classification of Diseases appointed by the American
edical Association with committees of other national medical
ganizations and with medical representatives of the Army, Navy,
ublic Health Service, and the Bureau of the Census,1 it was
freed : ^
" That practical suggestions be framed relative to the reporting
causes of death and of sickness by physicians, and that a list of
1e most undesirable terms frequently employed be brought to
,eir attention with the recommendation that they be disused."
In framing the following list of undesirable terms use has been
lade of the London Nomenclature, the Bellevue Nomenclature,
.nd especially of the " Suggestions to Medical Practitioners respect-
ng Certificates of Causes of Death," issued by the Registrar-
general of England and Wales, October, 19n.

^It is understood that the
term criticised is in the REASON WHY UNDESIEABLE, AND
low, without further STATEMENT OF CAUSE OF DEATH.
explanation or Quali
fication, )

' Abscess." "Abscess of Was it tuberculous or due to other in

brain," "Abscess of fection ? Traumatic ? The return of
lung" etc. "Abscess," unqualified, is worthless.
State cause (in which case the fact
of " abscess " may be quite unimpor
tant) and location.

''Accident" " Injury" Impossible to classify satisfactorily.

" External causes," Always state (1) whether Acciden
" Violence" Also tal, Suicidal, or Homicidal; and
more specific terms, as (2) Means of inlury (e. g., Railroad
" Drowning^' " Gun accident). The lesion (e. g., Frac
shot" which might be ture of skull) may be added, but is
cither accidental, sui of secondary importance for general
cidal, or homicidal. mortality statistics.

"Anasarca," "Ascites"'_ See "Dropsy."

1 Mortality Statistics, 1907, p. 19.


Reason Why Undesieable, and

Undesieable Teem. Suggestion foe Moee Definite
Statement of Cause of Death.

"Atrophy," "Asthenia," Frequently cover tuberculosis and other

definite causes. Name the r"
"Debility/' "De
cline," "Exhaus causing the condition.
tion," " Inanition"
" Weahness" and
other vague terms.
"Bloodpoisoning" See "Septicemia." Syphilis ?
" Cancer" " Carcino In all cases the ( or part first af-
ma ""Sarcoma,' ' etc. fected by c l be specified.
( Catarrh" Term best avoided, if possible.
' Cardiac insufficiency," See " Heart disease " and " Heart
" Cardiac degenera failure."
tion" "Cardiac
weahness," etc.
'Cardiac dilatation Do not report when a mere terminal
condition. State cause.
'Cellulitis" See "Abscess," "Septicemia."
" Cerebrospinal menin See "Meningitis."
" Congestion," " Conges Alone, the word " congestion ' ' is worth
less, and in combination it is almost
tion ofbowels," " Con equally undesirable. If the disease
gestion of brainf" amounted to inflammation, use the
" Congestion of hid
neys/ " Congestion proper term (lobar pneumonia,
chronic nephritis, enteritis, etc.);
of lungs" etc. merely passive congestion should
not be reported as a cause of death.
State the primary cause.
*" Convulsions" " Ec "It["isConvulsions
hoped that this indefinite term
''] will henceforth be
lampsia," "Fit" or restricted to those cases in which the
"Fits." true Cause of that symptom can not
be ascertained. At present more than
eleven per cent of the total deaths
of infants under one year old are
referred to 'convulsions' merely."
Registrar-General. "Fit.This is
an objectionable term ; it is indis
criminately applied to epilepsy,
convulsions, and apoplexy in differ
ent parts of the country."Dr.
Farr, in First Rep. Reg.- Gen., i8jq.

' Croup'' "Croup" is a most pernicious term

from a public health point of view,
is not contained in any form in the
London or Bellevue Nomenclatures,
and should be entirely disused.
Write Diphtheria when this disease
is the cause of death.

' Dentition" ' Teeth- State disease causing death.


' Disease," " Trouble," Name the disease, e. g., Lobar pneu
or '' Complaint" of monia, Tuberculosis of lungs,
[any organ] e. g., Chronic interstitial nephritis, Syphi
" Lu n g trouble," litic gumrnui of brain, etc.
'' Kidney complaint"
" Diseuse of brain/'

'Dropsy" "'Dropsy' should never be returned

as the cause of death without particu
lars as to its probable origin- e. g., in
disease of the heart, liver, kidneys,
etc."Registrar-General, Name
the disease causing (the dropsy
and) death.

' Edema of lungs" Usually terminal. Name the disease

causing the condition.

' Fever" Name the disease, as Typhoid fever,

Lobar pneumonia. Malaria, etc., in
which the " fever" occurs.

' Fracture ," " Fracture Indefinite; the principle of classifica

of skull," etc. tion for general mortality statistics is
not the lesion but (1) the nature of
the violence that produced it
(Accidental, Suicidal, Homicidal),
and (2) the Means of inlury.

' Gastritis," "Gastr1c Frequently worthless as a statement of

catarrh" "Acute in the actual cause of death; the terms
digestion." should not be loosely used to cover
almost any fatal affection with irri
tation of stomach. Gastroenteritis?
Acute or chronic, and cause ?

General decay" etc.


Reason Why Undesieable, and

Undesieable Teem. Suggestion foe Moee Definite
Statement of Cause of Death.

' Heart disease" The exact form of the cardiac affec

" Heart trouble" tion, as Mitral regurgitation, Aortic
even " Organic heart stenosis, or, less precisely, as Valvu
trouble." lar heart disease, should be suited.
' Heartfailure" " Car "Heartfailure" is a recognized syn
diac weahness" onym, even among- the laity, for ig
'' Cardiac asthenia," norance of the cause of death on the
" Cardiac exhaus part of the physician. Such a re
tion" "Paralysis of turn is forbidden by law in Connecti
the heart" etc. cut. If the physician can make no
more definite statement, it must be
compiled among the class of ill-de
fined diseases {not under Organic
heart disease)
' Hemorrhage " "Hem Frequently mask tuberculosis or deaths
optysis" "Hemor from injuries (traumatic hemor
rhage of lungs." rhage) , Puerperal hemorrhage, or
hemorrhage after operation for va
rious conditions. What was the
cause and location of the hemor
rhage ? If from violence, state fully
' Hydrocephalus " "It is desirable that deaths from hy
drocephalus of tuberculous origin
should be definitely assigned in the
certificate to Tuberculous menin
gitis, so as to distinguish them from
deaths caused by simple inflamma
tion or other disease of the brain or
its membranes. Congenital hydro
cephalus should always be returned
as such."Registrar-General*
"Hysterectomy" See " Operation"
"Infantile asthenia " See "Atrophy."
"Infantile atrophy"
"Infantile debility"
" Infantile maras
mus" etc.
" Infantile paralysis " This term is sometimes used for pa
ralysis of infants caused by instru
mental delivery, etc. The impor
tance of the disease in its recent
endemic and epidemic prevalence in
the United States makes the exact
and unmistakable expressions Acute
anterior poliomyelitis or Infantile
paralysis (acute anterior poliomye
litis) desirable.



' Inflammation "_ Of what organ or part of the bod

Cause ?

' Laparotomy " See " Operation."

Malignant," "Malig Should be restricted to use as quali

nant disease " cation for neoplasms; see Tumor.

"Malnutrition" See "Atrophy."

" Marasmus" This term covers a multitude of wort

less returns, many of which cot
be made definite and useful by g:
ing the name of the disease causi
the "marasmus" orwasting Ith
been dropped from the English M
menclature since 1885 ("Marasm,
term no longer used " ) T
Bellevue Hospital Nomenclau
also omits this term.

' Meningitis," " Cere Only two terms should ever be used
bral meningitis," report deaths from Cerebrospir
" Cerebrospinal men- (ever, synonvm, Epidemic cerebi
ingit is ," " S'p i n al Spinal meningitis, and they sho,
meningitis " be written as above and in no oil
way It matters not in the use of t
latter term whether the disease
actually epidemic or not in the loc
ity. A single sporadic case sho1
be so reported. The first term (Cei
brosplnal fever) is preferable 1
cause there is no apparent objecti
to its use for any number of cas
No one can intelligently classify su
returns as are given in the marg
Mere terminal or symptomatic 1n*
ingitis should not be entered at all
a cause of death; name the diset
in which it occurred Tubrculo
meningitis should be reported

' Natural causes"'_ This statement eliminates exten

causes, but is otherwise of lit
value. What disease (probab
caused death?



e," "Senilitv," Too often used for deaths of elderly

persons who succumbed to a definite
disease. Name the disease causing

deration" " Surf All these are entirely indefinite and

a I ope r a t i , unsatisfactoryunless the surgeon
' Surgical shock, desires his work to be held primarily
' A m p u tatin, responsible for the death . Name the
41y sterecto my, disease , abnormal condition, or form
' Laparotomy" etc. of external violence (Means o
death; accidental, suicidal, or
homicidal?), for which the opera
tion was performed. If death was
due to an anesthetic (chloroform,
ether, etc.), state that fact and the
name of the anesthetic.

1ralvsis," " General The vague use of these terms should

-aralysis" " Pare be avoided, and the precise form
is" " Generalpare stated, as Acute ascending paralysis,
is" " Palsy" etc. Paralysis agitane, Bulbar paralysis,
etc. Write General paralysis of the
Insane in full, not omitting any part
of the name; this is essential for sat
isfactory compilation of this cause.
Distinguish Paraplegia and Hmi
plgie; and in the latter, when a
sequel of Apoplexy or Cerebral
hemorrhage, report the primary

eritonitis'' ' Whenever this condition occurs

either as a consequence of Hernia,
Perforating ulcer of the stomach or
bowel [Typhoid lever?], Appendi
citis, or Metritis (puerperal or other
wise), or else as an extension of mor
bid processes from other organs
[Name the disease], the fact should
be mentioned in the certificate."
Registrar-General. Always specify
Puerperal peritonitis in cases result
ing from abortion, miscarriage, or
labor at full term. Always state if
due to tuberculosis or cancer. When
traumatic, report means of Injury
and whether accidental, suicidal, or

Reason Why Undesieable, and

Undesieable Teem. Suggestion foe Moee Definite
Statement of Cause of Death.
' Pneumonia?' " Ty "Pneumonia," without qualification, is
phoidpneumonia," indefinite ; it should be clearly stated
either as Bronchopneumonia or
Lobar pneumonia. The term
Croupous pneumonia is also clear.
"The term 'TyPhoid pneumonia'
' should never be employed, as it may
mean either Enteric fever [Typhoid
fever] with pulmonary complica
tions, on the one hand, or Pneumonia
with so-called typhoid symptoms on
the other."Registrar-General.
When lobar pneumonia or broncho
pneumonia occurs in the course of or
following a disease, the primary
cause should be entered first, with
duration, and the lobar pneumonia
or bronchopneumonia be entered be
neath as the contributory cause, with
duration. Do not report "Hypostatic
pneumonia " or other mere terminal
conditions as causes of death when
the disease causing death can be
" Ptomain poisoning? These terms are used very loosely and
"Autointoxication," it is impossible to compile statistics
" Toxemia," etc. of value unless greater precision can
be obtained. They should not be
used when merely descriptive of
symptoms or conditions arising in the
course of diseases, but the disease
causing death should alone be
named. "Ptomain poisoning"
should be restricted to deaths result
ing from the development of putre
factive alkaloids or other poisons in
food, and the food should be named,
as Ptomain poisoning (mussels),

"Pulmonary c o nge j- See "Congestion " "Hemorrhage."

tion," "Pulmonary
"Pyemia" See "Septicemia"
"Septicemia " "Sepsis" Always state cause of this condition,
"Septic infection" and, if localized, part affected. Pu
etc. erperal? Traumatic (see p. n)?
"Shoch" (post-operative) See "Operation."



"Specif1c " . The word specific should never be used

without further explanation. It may
signify syphilitic, tuberculous',
gonorrheal, diphtheritic, etc.
Name the disease.
Tabes mesentericaf '' The use of this term ['' Tabes mesen-
" Tabes" terica "] to descr1be tuberculous
disease of the peritoneum or intes
tines should be discontinued, as it is
frequently used to denote various
other wasting diseases which are not
tuberculous. Tuberculous perito
nitis is the better term to employ
when the condition is due to tuber
cle.''Registrar-General. Tabes
dorsalls should not be abbreviated
to " Tabes."
' Teething:" See " Dentition."
' Toxemia" See " Ptomain poisoning"
' Tuberculosis " ...... The organ or part of the body affected
should always be stated, as Tuber
culosls of the lungs, Tuberculosis
of the spine. Tuberculous menin
gitis. Acute general mlliary tuber
culosis, etc.
' Tumor" " Neoplasm,' These terms should never be used with
" New growth." out the qualifying words Malignant,
Nu nuialignant, or Benign. If ma
lignant, they belong under Cancer,
and should preferably be so reported,
or under the more exact terms Car
cinoma, Sarcoma, etc. In all cases
the organ or part affected should be
' Uremia"^ Name the disease causing death, i. e.,
the primary cause, not the mere ter
minal conditions or symptoms, and
state the duration of the primary
'Uterine hemorrhage" -- See ''Hemorrhage."

The physician's responsibility is usually confined to the correct

atement of the cause of death, but be may in some instances fill
ut the entire certificate, or he may note errors in the statement of
le personal and statistical particulars, the correction of which will
e of service to statistical accuracy as well as insure more truth-
ul legal records. Hence his interest is solicited in the complete
less and correctness In all respects of all certificates passing
hrough his hands, and more especially in the correct statement
of sex, color, marital condition, age, occupation, birthplace, birth
place of father, birthplace of mother, and length of residence
when the latter is required.
Age is of special importance, and as a check on the accuracy of
the statement, the date of birth is also required. For infants
under 1 day old state the hours, or even the minutes if less than
1 hour Old. This is necessary in order that stillbirths may be dis
tinguished with absolute precision from deaths of children born
alive. Stillbirths may be registered, under various laws, either as
births, as deaths, or, preferably, both as births and deaths; they
should be compiled, in statistical tables, neither as births nor
deaths, but separately as stillbirths' A Stillborn child Is dead
at the moment of birth, hence no age whatever, not even 1
minute, should be entered under the statement of age, but the
space should be filled with a cipher ("0"). Conversely, if the
child lived any time whatever, even a single minute, after birth,
"Stillborn" should not be reported as the cause of death.
Precise statement of OCCUPATION (including Special occu
pation and Industry) is very important, so that the relative health-
fulness of various pursuits can be known. The instructions on the
back of the Revised United States Standard Certificate of Death,1
together with any additional instructions approved by state or
municipal authority, should be carefully followed in this respect,
and physicians should especially note occupational influences
affecting the cause of death.
The statement should include (a) Trade, profession, or particu
lar kind ol work (e. g., Spinner); and (b) General nature of
Industry, business, or establishment in which employed (or em
ployer), whenever the latter is indicated (e. g., Cotton mill).
i Adopted by the American Public Health Association and ap
proved by the Bureau of the Census for use beginning January 1,
., eo. See blanks as used by many states, or copies will be sent by
the Bureau of the Census upon request, together with draft of
' Model Law. A reduced facsimile is shown on p. 3*

This booklet is distributed to all physicians in the United States,

eluding those residing in states having incomplete registration
deaths, as well as in the states of the registration area from
hich transcripts of death certificates are received by the Bureau
the Census and compiled for the annual report on Mortality
Careful observance of the suggestions herein contained will result
i great improvement in the quality of the returns received from
egistration states and cities, and knowledge of the necessity of
.ccurate records of deaths for sanitary and other important pur
poses may lead physicians in nonregistration states to labor for the
enactment of adequate legislation. Advice and aid will be given
by the Bureau of the Census, and by the American Medical Asso
ciation and American Public Health Association cooperating, in
compliance with the Joint Resolution of Congress, approved Feb
ruary 11, 1903, some clauses of which are as follows :
" Whereas the registration of births and deaths at the time of
their occurrence furnishes official record information of much value
to individuals; and
"Whereas the registration o deaths, with Information upon
certain points, is essential to the progress of medical and sanitary
sclence In preventing and restricting disease and in devising and
applying remedial agencies; and
* * * * *
"Whereas the American Public Health Association and the
United States Census Bureau are now cooperating in an effort to
extend the benefits of registration and to promote its efficiency by
indicating the essential requirements of legislative enactments de
signed to secure the proper registration of all deaths and births and
the collection of accurate vital statistics, to be presented to the atten
tion of the legislative authorities in nonregistration states, with the
suggestion that such legislation be adopted: Now, therefore,
"Resolved by the Senate and House of Representatives of the
united States of America in Congress assembled, That the
Senate and House of Representatives of the United States hereby
expresses approval of this movement and requests the favorable
consideration and action of the state authorities, to the end that
the United States may attain a complete and uniform system of
Registration Area- for Deaths.
The progress of the movement for better vital statistics in the
United States is summarized below, and the present extent of the
registration area for deaths (states included in 1916). and its growth
since 1900 may be seen in the Map on the opposite page. In this
Map the registration states in 1900 (calendar year) are in black, the
registration states added to the registration area during the per:
1900 to 1916 and now constituting a part of it are shaded, and
states not yet includedsome of which, however, have recer
passed laws of a satisfactory characterare left white.
Beginning with the Seventh Census (1850) an effort was madi
collect statistics of deaths through the enumerators of populal
as a part of the general census. This method was unsuccessful
giving reliable resultsvital statistics can not be obtained
enumeration but only by immediate registrationbut the j
was pursued at each subsequent census until the Thirteenth ( 19
when it was dispensed with entirely.
In 1880 the results of registration of deaths under state
municipal authority were utilized, thus establishing the registra
area. This consisted of only two states, Massachusetts and I
Jersey, the District of Columbia, and certain registration clth
nonregistration states. The aggregate population represented
8,538,366, or 17.0 per cent of the total population of contin
United States.
For 1890 there were added the states of Connecticut, Delai
(not entitled to admission and dropped at the next census), .
Hampshire, New York, Ehode Island, and Vermont, -.
increased the percentage to 31.4.
For the census year 1900 (ending May 31), there were a
Maine and Michigan, raising the percentage to 37.9.
The compilations theretofore made were only for census y
there being no data for the intercensal period. Beginning wit
calendar year 1900, and since the establishment of the Bure
the Census upon a permanent basis, there have been regular a
reports (Mortality Statistics, 1900 to 1914) and large additk
the registration area due to the constant efforts made b
bureau in cooperation with medical and sanitary organic
and with state authorities.
Indiana was added for the calendar year 1900.
California, Colorado, Maryland, Pennsylvanfa, and
Dakota (dropped in 1910) were added for 1906; Washingtc
Wisconsin were added for 1908 ; Ohio for 1909; Minnesota,
tana, and Utah for 1910; Kentucky and Missourf for 1911
glnla for 1913; Kansas for 1914; and North Carolina and
Carolina for 1916. The aggregate estimated population for t
year is 71,621,502, or 70.2 per cent of the total estimated p
tion of the United States.
In 1914, for which the mortality report has just been :
898,059 deaths were returned from the registration area con
of twenty-four states, the North Carolina municipalities
population and over in 1910, the District of Columbia, and
two registration cities in nonregistration states. The est
population of these states and cities was 65,989,295, or 6
- . of the total estimated population of the United States.
fundamental importance of accurate vital statistics for the
rotection of human health and life is universally recognized, and
greater attention is being given to the subject throughout the
country. Especially is there widespread interest in the South,
-which has heretofore been only slightly represented by reliable state
registrationto its large sanitary and financial loss, because vague
rumors of high mortality can only be confuted by accurate regis
tration of deaths.
The Model Lcvw and Essential Pr1nciples of Registration.
Practically all the progress made in this country during the past
decade in the extension of adequate registration laws and the pro
motion of uniformity and comparability of the mortality statistics
is due to the Model Law. This law was based upon tested princi
ples of successful registration, as worked out by practical registra
tion officials m the American Public Health Association with the
aid of the Bureau of the Census. It has lately been revised by a
committee formed of representatives from the American Medical
Association, American Public Health Association, American Bar
Association, Children's Bureau, and the Bureau of the Census. Its
operation rapidly brought states such as Pennsylvania, Ohio, Mis
souri, Kentucky, Virginia, Kansas, North Carolina, and South
Carolinawhich prior to its adoption had had no, or only utterly
worthless, vital statisticsinto the registration area. Very re
cently it has been adopted by Arkansas, Florida, Illinois, Miss
issippi, and Tennessee. Other states have adopted it without
giving it adequate support (Georgia and North Dakota). Some of
the older registration states, with fairly good laws, have amended
them to comply with the provisions of the Model Law (Massa
chusetts) or adopted it entire (New York, 1913). From this ex
tended experience, we can confidently state that the Model Law,
with reasonable provision for Its support and with a fairly capable
administrator In charge, will yield successful results in the
registration of deathsand better results in the registration of
births than any other law.'
The essential principles of registration as embodied in the
Model Law may be briefly summarized : (1) Immediate registra
tion (deaths before interment, births within ten days and not, com-

iCopies of the Model Law as published in the pamphlet " Why

Should Births and Deaths Be Registered?" may be obtained from
Dr. Frederick R. Green, Secretary, Council on Public Health,
American Medical Association, 535 Dearborn Avenue, Chicago,
and from the Bureau of the Census, Washington. Valuable pam-
phlets showing the importance of such legislation are published by

ftj ? Longevity."
pulsorily, less than three days in rural districts); (a) Standard cer
tificates (copies on request); (3) Compulsory burial or removal
permits for deaths, and some effective check on the accuracy of
registration for births (by deaths of infants under 1 year, special
enumeration, newspapers); (4) Efficient local registrars, properly
compensated (twenty-five cents) for each certificate registered and
returned in compliance with law only, and so distributed that the
least possible inconvenience will be caused physicians and under
takers in filing certificates; (5) Sole responsibility for registering
deaths and obtaining burial or removal permit In advance of in
terment upon undertaker or person disposing of body and sole
responsibility for registering births, within the time limit set by
law, upon the attending physician or midwife (parent in absence
of such attendance); (6) An efficient State Registrar, with full
power and responsibility to enforce the law, in direct connection
with the local registrars (any county official intervening in any ca
pacity between the State Registrar and local registrars means
failure of the law); (7) Prompt monthly returns of the original
certificates from the local registrars to the State Registrar, with
report of "No births'' or "No deaths1' when such was the case
and official statement of completeness of registration or report of
delinquents; (8) All this is useless to secure complete legal records
and statistics of tbe highest practical value unless penalties are pro
vided in the law, and those PENALTIES ARE ENFORCED.
Imperfect Enforcement of Birth Registration Laws.
No state in the Union can claim at the present time complete
registration of all births that occur. Even in the oldest registration
states (e. g., Massachusetts, Connecticut) some births are not
recorded. Considering the short time that it has been in operation
in any state, the Model Law has afforded better results than any
other birth registration law in this country. This is well shown
by the results in Pennsylvania, Ohio, Missouri, and Kentucky.
As shown in Census Bulletin 112, Mortality Statistics, zoix, only a
few states registered as many births in 1910 as there were infants
under 1 year of age in the population. The births should consid
erably exceed the infants under 1 year of age owing to the number
born and dying during the census year. Only eleven states ex
ceeded this low limit, namely, Connecticut, Indiana, Maine, Mas
sachusetts, Michigan, New Hampshire, New York, Ohio, Penn
sylvania, Rhode Island, and Vermont; and of these only three
(Connecticut, Massachusetts, Rhode Island), exclusive of cities of
500,000 population and over, showed for the following year (1911)
births exceeding infants under 1 year of age by as much as 10 per
cent. Rates of infantile mortality are worthless in almost all the
states on account of the imperfect registration of births. But
Kentucky and Missouri each afforded, for the first calendar year
of the operation of the Model Law (1911), returns of births nearly
equal to the number of infants in the population, and for the fol
lowing year (1912) slightly in excess. The support of the pro
fession, press, and people must be obtained in order to insure
effective registration of births, but with this once gained, the
thorough continuous enforcement of the Model Law will yield
as excellent results for births as for deaths.
The necessity of birth registration for the saving of the lives of
infants and children is well shown in the first publication of the
Children's Bureau,! Department of Labor:
"The Children's Bureau devotes this, its first monograph, to
birth registration, because the adequate recording of births is
fundamentally necessary to the studies of child welfare which the
bureau is directed by law to undertake, and, more important, be
cause universal birth registration will prove of great practical
value to the people of the United States.
" Convinced that the most effective work in behalf of public
health that can be done in this country to-day lies in the prevention
of infant mortality, the Children's Bureau is brought to the
necessity of appealing for such legislation and such local records
as will indicate where and when the babies are born and where
and when they die, as a preliminary to an intelligent study of
the subject."
Will the physicians of the United States respond to this appeal?
What is needed is, first, enactment of adequate laws where
they do not now exist, and then, practically everywhere in the
BIRTH REGISTRATION LAWS. In many localities the
physicians are far more delinquent than the midwives with respect
to the reporting of births. The worthlessness of a large number
of our birth registration laws depends upon the noaenforcement
of the penalties of the laws by those officials who are charged
with their enforcement, largely from unwillingness to antagonize
prominent members of the medical profession who occasionally,
or regularly, disregard their duties relative to the registration of
births. The profession should encourage the effective adminis
tration of such laws by cheerfully and promptly complying with
them, and by supporting the efforts of health officers and other
registration officials in the performance of their plain duty. Have
you failed, Doctor, to record any birth that has occurred in
your practice? Your neglect may mean loss of money, lack of
proof of legitimacy, difficulty in proof of age for the requirements
of school and labor laws, and may perhaps work an irreparable
wrong to the child in future years. If so, please complete your
service to the family by registering the birth. DO IT NOW I
1 Monograph No. 1Birth Registration.
In 1915 a registration area for the annual collection of birtfc
statistics was established by the Bureau of the Census, comprising
the states of Maine, New Hampshire, Vermont, Massachusetts
Rhode Island, Connecticut, New York, Pennsylvania, Michigan,
and Minnesota, and the District of Columbia, with an estimate;
population of 31,150,803, or 31 per cent, of the total estimated
population of the United States. The statistics will cover the
calendar year 1915 and they will be published late in 1916.